Tumor Necrosis Factor Inhibitor Therapy in Polyarteritis Nodosa: Expanding Evidence From Systemic to Cutaneous Disease

To the Editor:

We read with great interest the recent article by Dr. Harama et al published in The Journal of Rheumatology regarding the off-label use of tumor necrosis factor inhibitors (TNFi) in the management of cutaneous polyarteritis nodosa (PAN)-associated refractory leg ulcers.¹ The authors present compelling evidence supporting the therapeutic efficacy of this drug class in a clinical indication not currently supported by established treatment guidelines.

We would like to contribute to this important clinical dialogue by drawing attention to our previously published experience with this therapeutic approach. In our study,² we reported on the clinical outcome of infliximab therapy in 9 patients with severe systemic and refractory PAN after failure of standard treatment. Eight of these 9 patients presented with concurrent cutaneous involvement in addition to other systemic clinical manifestations. Our findings demonstrated that infliximab therapy, initiated after conventional treatment failure, achieved significant clinical improvement across all patients while enabling dose reduction of prednisone and other immunomodulatory agents, with an acceptable safety profile.

These outcomes align with the conclusions presented by Harama et al,¹ particularly regarding cutaneous manifestations of PAN. The concordance between our earlier observations and the current findings strengthens the evidence supporting this therapeutic approach.

These converging data warrant consideration for inclusion in future evidence-based treatment algorithms. We concur with the authors’ conclusion that further prospective randomized controlled studies are needed to establish the optimal dosing regimens, treatment duration, and patient selection criteria for this indication.

We commend the authors for their valuable contribution to the literature and anticipate further research developments in this promising area.

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